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Based on record review and interview, the hospital failed to protect and promote each patient's rights,

citing 1 of 20 patients (Patient #1) hospitalized from 5/13/2023 through 5/17/2023:

~ Failed to provide the complainant with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance of quality of care, the results of the grievance process, and the date of completion, for the 5/17/2023 negligence complaint by Patient #1's guardian.

Cross Reference Tag A0123

~ Failed to communicate to the mother/guardian for the care plan/discharge decisions while hospitalized.

Cross Reference Tag A0130

~ Failed to ensure nutritional and psychological needs were not met while hospitalized and post-acute.

Cross Reference Tag A0144

Based on record review and interview, the hospital failed to provide the complainant with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance of quality of care, the results of the grievance process, and the date of completion,

citing the hospital failed to review and resolve 1 of 20 patients (Patient #1) 5/17/2023 negligence complaint.

Patient #1's documented weights showed a loss of 7 kilograms/15.4 pounds since the 5/13/2023 admission.

Findings

Patient #1 record reflected a 20-year-old incapacitated adult/child who is non-verbal, legally blind, autistic, intellectual disabilities who required total care including using a sippy cup, needing to be hand feed pureed food, given liquid medications, and changing diapers. The mother said the child had not eaten for five (5) days since the primary care giver (grandfather) was hospitalized on Monday (5/08/2023). The patient's primary caretaker was currently in the hospital. Patient has been refusing to interact and allow for care. Patient here is malodorous and does appear disheveled. The 5/13/2023 weight was 63.2 kilograms (139.04 pounds) on admission. The admit diagnosis was Failure to Thrive. Other diagnosis included dehydration; disorders of nutrition, metabolism, fluid; and hydrocephalus status post VP (ventriculoperitoneal) shunt. The patient was discharged 5/17/2023 without stabilization of the nutritional and psychological issues.

The hospital's 5/17/2023 incident report documented multi-level care staff, supervisors, and management were aware of the mother's discharge complaint of the facility's negligence and her intent to take the child to a children's hospital for care once discharged.

There was no investigation or Resolution letter for the complaint.

During record review and interview on 8/10/2023 at 10:23 AM, Personnel #1 and #2 were present. Personnel #2 was asked about complaints for the patient. Personnel #2 stated I remember being notified of an issue at some point. Mom was not happy and taking him to a children's hospital. She was given my information if she wanted to file a formal complaint. She never notified me. There is no grievance on the grievance log. Personnel #1 later provided the hospital's reports. Personnel #1 was asked with both reports, did quality and Med staff review this situation. Personnel #1 stated No. Personnel #1 was asked to confirm for this patient situations there were multiple failed processes. Personnel #1 stated yes.

The facility's April 2022 revised "Patient Rights and Responsibilities" policy required, "Considerate and Respectful Care...To receive ethical, high-quality, safe and professional care without discrimination; To be free from all forms of abuse and harassment; To be treated with consideration, respect and recognition of their individuality; To be informed of his/her health status in terms that patient can reasonably be expected to understand, and to participate in the development and the implementation of his/her plan of care and treatment...To be informed of all appropriate alternative treatment procedures...To safe, secure and sanitary accommodation and a nourishing, well balanced and varied diet...To a prompt and reasonable response to questions and requests for service...To access protective and advocacy services..."

The SUBSEQUENT hospital's record reflected the patient was admitted on 5/17/2023 (same day) with dehydration and weighed 56.2 kilograms (Loss of 7 kilograms). An NG (naso-gastric) tube feedings were tolerated. A G-Tube was place on 5/23/2023 due to the patient's aversion to eat. Re-feeds started and he tolerated feedings prior to discharging on 5/24/2023 to a skilled nursing facility...brought in from an outside facility...they (outside hospital) discharged today despite not having clinical improvement. Family is very concerned that he is still not taking anything to eat or drink.

Based on record review and interview, the hospital failed to involve the guardian in the development and implementation of the care plan/decision to discharge home,

citing 1 of 20 patients (Patient #1) guardian was not involved in the care plan/discharge decisions.

~ Failed to communicate to the mother/guardian during the hospitaliztion from 5/13/2023 through 5/17/2023.

Findings

Patient #1 record reflected a 20-year-old incapacitated adult/child who is non-verbal, legally blind, autistic, intellectual disabilities who required total care including using a sippy cup, needing to be hand feed pureed food, given liquid medications, and changing diapers. The mother said the child had not eaten for five (5) days since the primary care giver (grandfather) was hospitalized on Monday (5/08/2023). The patient's primary caretaker was currently in the hospital. Patient has been refusing to interact and allow for care. Patient here is malodorous and does appear disheveled. The 5/13/2023 weight was 63.2 kilograms (139.04 pounds) on admission. The admit diagnosis was Failure to Thrive. Other diagnosis included dehydration; disorders of nutrition, metabolism, fluid; and hydrocephalus status post VP (ventriculoperitoneal) shunt. The patient was discharged 5/17/2023 without stabilization of the nutritional and psychological issues.

Patient #1's record did not document physician communication to the patient's mother/guardian for 5/14/2023; 5/15/2023; 5/16/2023; and 5/17/2023.

The 5/13/2023 physician orders were not followed/acted on:
- 07:33 AM Place call to BH (Behavioral health) assessor Psych / Abuse workup;

- 10:50 AM Case management...enteral feeding; AND

- 1:09 PM Case management...Home Health OT/PT/RN eval (Occupational/Physical Therapy and Registered Nurse).

There was no indication the orders were implemented/acted on.

There was no nutritional intake, or hospital intervention implemented to ensure the child's nutritional requirements were met while the patient was hospitalized from 5/13/2023 through 5/17/2023 or post-acute.

The 5/16/2023 Discharge Summary reflected the Dietician was consulted to assist as patient was refusing to eat by mouth...Patient will be taken home by his mother...Case management was consulted to assist with placement. At this time per case management patient will be discharged back home with his mom for further management...Follow-up Primary care provider...Resume home diet/feeds...Discharge Home/Self-care...

The hospital's 5/17/2023 incident report documented multi-level care staff, supervisors, and management were aware of the mother's discharge complaints of the hospital's negligence to feed the child and her intent to take the child to a childrens hospital for care once they discharged him.

During record review and interview on 8/10/2023 at 10:23 AM, Personnel #1 was asked for the Behavioral Health Assessor report. Personnel #1 stated I am not finding one. Personnel #1 was asked for the order. Personnel #1 found the 5/13/2023 07:33 order. Personnel #1 looked for documentation again without finding any. Personnel #1 was asked if they stabilized Patient #1's his eating issue prior to discharge. Personnel #1 stated no. Personnel #1 asked if there was physician documentation of communication with mother/guardian. Personnel #1 stated no, no documentation of trying to talk to the mother after the ED (emergency department).

During an interview on 8/10/2023 at 4:00 PM with the social worker, Personnel #5 was asked to explain what occurred with the patient. Personnel #5 stated patient came in because of grandfather's medical complications. He lived with grandfather, and they admitted (Patient #1) because they were told he had no caregiver. Once I found out there was a state worker, APS (Adult Protective Services), and Lifepath. I coordinated with them. They (APS) spoke with mom. APS told me the mom was not able to care for him. Personnel #5 was asked I am hearing that you coordinated with everyone else, but did not talk to mom. Did you speak to mom. Personnel #5 stated only once to tell her he would discharge. Personnel #5 was asked as the patient advocate what should be done if a patient won't eat. Personnel #5 stated ensure he is getting nutrients to be healthy. Personnel #5 was asked why he was discharge if we did not take care of the eating issue. Personnel #5 stated he was discharged because the doctor ordered his discharge.

The SUBSEQUENT hospital's record reflected the patient was admitted on 5/17/2023 (same day) with dehydration and weighed 56.2 kilograms (Loss of 7 kilograms). An NG (naso-gastric) tube feedings were tolerated. A G-Tube was place on 5/23/2023 due to the patient's aversion to eat. Re-feeds started and he tolerated feedings prior to discharging on 5/24/2023 to a skilled nursing facility...brought in from an outside facility...they (outside hospital) discharged today despite not having clinical improvement. Family is very concerned that he is still not taking anything to eat or drink.

Based on record review and interview, the hospital failed to ensure care in a safe setting,

citing 1 of 20 patients (Patient #1) nutritional and psychological needs were not met while hospitalized from 5/13/2023 through 5/17/2023 and post-acute.

Patient #1's documented weights showed a loss of 7 kilograms/15.4 pounds since the 5/13/2023 admission.

Findings

Patient #1 record reflected a 20-year-old incapacitated adult/child who is non-verbal, legally blind, autistic, intellectual disabilities who required total care including using a sippy cup, needing to be hand feed pureed food, given liquid medications, and changing diapers. The mother said the child had not eaten for five (5) days since the primary care giver (grandfather) was hospitalized on Monday (5/08/2023). The patient's primary caretaker was currently in the hospital. Patient has been refusing to interact and allow for care. Patient here is malodorous and does appear disheveled. The 5/13/2023 weight was 63.2 kilograms (139.04 pounds) on admission. The admit diagnosis was Failure to Thrive. Other diagnosis included dehydration; disorders of nutrition, metabolism, fluid; and hydrocephalus status post VP (ventriculoperitoneal) shunt. The patient was discharged 5/17/2023 without stabilization of the nutritional and psychological issues.

There was no nutritional intake, or hospital intervention implemented to ensure the child's nutritional requirements were met while the patient was hospitalized from 5/13/2023 through 5/17/2023 or post-acute.

The 5/13/2023 Physician Orders were not implemented/acted on:
~ 07:33 AM Place call to BH (Behavioral health) assessor Psych / Abuse workup;

~ 10:50 AM Case management...enteral feeding; AND

~ 1:09 PM Case management...Home Health OT/PT/RN eval (Occupational/Physical Therapy and Registered Nurse).

There was no indication the orders were implemented/acted on.

During record review and interview on 8/10/2023 at 10:23 AM, Personnel #1 was asked for the Behavioral Health Assessor report. Personnel #1 stated I am not finding one. Personnel #1 was asked if they stabilized Patient #1's his eating issue prior to discharge. Personnel #1 stated no.

During an interview on 8/10/2023 at 4:00 PM with the social worker, Personnel #5 was asked to explain what occurred with the patient. Personnel #5 stated patient came in because of grandfather's medical complications. He lived with grandfather, and they admitted (Patient #1) because they were told he had no caregiver. Once I found out there was a state worker, APS (Adult Protective Services), and Lifepath. I coordinated with them. They spoke with mom. APS told me the mom was not able to care for him. Personnel #5 was asked I am hearing that you coordinated with everyone else, but did not talk to mom. Did you speak to mom. Personnel #5 stated only once about discharge. Personnel #5 was asked as the patient advocate what should be done if a patient won't eat. Personnel #5 stated ensure he is getting nutrients to be healthy. Personnel #5 was asked why he was discharge if we did not take care of the eating issue. Personnel #5 stated he was discharged because the doctor ordered his discharge.

During a telephone interview on 8/10/2023 at 5:00 PM with physicians, Personnel #3 and #4 were asked when a patient does not eat - what measures should be taken to ensure life. Personnel #3 stated it depends on the situation. This patient ate at home. This patient was refusing food from us. He did not recognize us. He would take sips and bites only, then stop. He was like a child. The best place for him was home with his family. We can't force them to eat. We tried our best to feed the patient. The family was inconsistent. Nurses tried their best. Personnel #4 stated he was a difficult case because of all the social factors. APS and the state were involved. They worked on placement and could not find placement for him. We can't tie him down to tube him when it isn't clinically indicated. He was stable, no signs of distress or dehydration, labs were good. Personnel #3 was asked if he spoke to mom. Personnel #3 stated I did the first day. Mom said she had to take care of the other kids. After day 1, Social Worker and Nursing kept in touch. At discharge, I spoke to mom. She was upset that patient would not have placement but discharged. I told her we needed the families help and no help came. He rejected our help because he doesn't recognize us. It is possible he was drinking when no one was with him. He used a sippy cup. No clinical signs of dehydration. We felt he would go back to eating when he was no longer in the hospital.

During record review and interview on 8/14/2023 at 1:52 PM, Personnel #2 was directed to the 5/13/23 10:50 Order for Case management that said enteral feeding and the 5/13/23 13:09 order for Case management that said Home Health OT/PT/RN eval (Occupational/Physical Therapy and Registered Nurse). Personnel #2 was asked where this was addressed. Personnel #2 reviewed the record and stated I don't see it. Personnel #2 was asked if the facility had a surgeon to place a G-tube. Personnel #2 stated yes.

The hospital's July 2022 "Physician Orders" policy reflected, "To provide safe and timely administration of all physician orders..."

The hospital's April 2022 revised "Patient Rights and Responsibilities" policy required, "Considerate and Respectful Care...To receive ethical, high-quality, safe and professional care without discrimination; To be free from all forms of abuse and harassment; To be treated with consideration, respect and recognition of their individuality; To be informed of his/her health status in terms that patient can reasonably be expected to understand, and to participate in the development and the implementation of his/her plan of care and treatment...To be informed of all appropriate alternative treatment procedures...To safe, secure and sanitary accommodation and a nourishing, well balanced and varied diet...To a prompt and reasonable response to questions and requests for service...To access protective and advocacy services..."

The SUBSEQUENT hospital's record reflected the patient was admitted on 5/17/2023 (same day) with dehydration and weighed 56.2 kilograms (Loss of 7 kilograms). An NG (naso-gastric) tube feedings were tolerated. A G-Tube was place on 5/23/2023 due to the patient's aversion to eat. Re-feeds started and he tolerated feedings prior to discharging on 5/24/2023 to a skilled nursing facility...brought in from an outside facility...they (outside hospital) discharged today despite not having clinical improvement. Family is very concerned that he is still not taking anything to eat or drink.

Based on record review and interview, the medical staff failed to ensure the quality of the medical care provided to patients, citing 1 of 20 patients (Patient #1) while hospitalized from 5/13/2023 through 5/17/2023 the physician failed:

~ to communicate to the mother/guardian throughout the hospitalization;

~ to ensure orders were followed for nutritional/psychological needs; AND

~ to ensure nutritional requirements were met.

The hospital failed to stabilize the patient's refusal to eat, identify the patient's lack of eating, and weight loss as a primary diagnosis.

Patient #1's documented weights showed a loss of 7 kilograms/15.4 pounds since the 5/13/2023 admission.

Cross Reference Tag A0347

Based on record review and interview, the medical staff failed to ensure the quality of the medical care provided to patients, citing 1 of 20 patients (Patient #1) while hospitalized from 5/13/2023 through 5/17/2023 the physician failed:

~ to communicate to the mother/guardian throughout the hospitalization;

~ to ensure orders were followed for nutritional/psychological needs; AND

~ to ensure nutritional requirements were met.

The hospital failed to stabilize the patient's refusal to eat, identify the patient's lack of eating, and weight loss as a primary diagnosis. Patient #1's documented weights showed a loss of 7 kilograms/15.4 pounds since the 5/13/2023 admission.

Findings

Patient #1 record reflected a 20-year-old incapacitated adult/child who is non-verbal, legally blind, autistic, intellectual disabilities who required total care including using a sippy cup, needing to be hand feed pureed food, given liquid medications, and changing diapers. The mother said the child had not eaten for five (5) days since the primary care giver (grandfather) was hospitalized on Monday (5/08/2023). The patient's primary caretaker was currently in the hospital. Patient has been refusing to interact and allow for care. Patient here is malodorous and does appear disheveled. The 5/13/2023 weight was 63.2 kilograms (139.04 pounds) on admission. The admit diagnosis was Failure to Thrive. Other diagnosis included dehydration; disorders of nutrition, metabolism, fluid; and hydrocephalus status post VP (ventriculoperitoneal) shunt. The patient was discharged 5/17/2023 without stabilization of the nutritional and psychological issues.

The 5/13/2023 ED (emergency department) Provider note reflected...stated complaint: Combative/refusing to eat...Free Text MDM (Medical Decision Making) Notes...presenting with concern for failure to thrive. Patient's primary caretaker currently in the hospital. Patient has been refusing to interact and allow for care. Patient here is malodorous and does appear disheveled. Mother later came to provide history regarding VP (ventriculoperitoneal) shunt. States that he has had no nystagmus. VP shunt series unremarkable. (named lab work) reviewed without evidence of significant leukocytosis, severe anemia, electrolyte abnormalities, acute kidney injury or elevated liver function tests. Noted some ketones in urine, suspect element of dehydration, given IV (intravenous) fluids. Family does not feel comfortable taking patient back home with them as primary caretaker likely will be unable to care for patient in the future due to recent dementia diagnosis. Will admit for care placement...Primary Impression: Failure to thrive Secondary Impressions: Dehydration, VP shunt status Disposition Decision: Admit...

Patient #1's record did not document physician communication to the patient's mother/guardian for 5/14/2023; 5/15/2023; 5/16/2023; and 5/17/2023.

The 5/13/2023 Physician Orders were not implemented/acted on:
~ 07:33 AM Place call to BH (Behavioral health) assessor Psych / Abuse workup;

~ 10:50 AM Case management...enteral feeding; AND

~ 1:09 PM Case management...Home Health OT/PT/RN eval (Occupational/Physical Therapy and Registered Nurse).

Patient #1's 5/15/2023 Nutrition Assessment reflected...refusing foods...nurse trying to feed...Nutrition order: Pureed/ No Straw...PO (by mouth) Intake zero percent for today's meals...weight kg (kilograms): 63.2...Nutrition Calculations - Calories a day: 1903...Nutrition problem 1: Inadequate oral intake...Collaboration with other: Enteral Nutrition...patient is refusing to eat food. Recommend alternate source for nutrition...obtain 1 to 2 x (times) weekly weights for monitoring...

There was no nutritional intake, or hospital intervention implemented to ensure the child's nutritional requirements were met while the patient was hospitalized from 5/13/2023 through 5/17/2023 or post-acute.

The 5/16/2023 Discharge Summary reflected the Dietician was consulted to assist as patient was refusing to eat by mouth...Patient will be taken home by his mother...Case management was consulted to assist with placement. At this time per case management patient will be discharged back home with his mom for further management...Follow-up Primary care provider...Resume home diet/feeds...Discharge Home/Self-care...

The hospital's 5/17/2023 incident report documented multi-level care staff, supervisors, and management were aware of the mother's discharge complaints of the hospital's negligence and her intent to take the child to a children's hospital for care once discharged.

During record review and interview on 8/10/2023 at 10:23 AM, Personnel #1 was asked for the Behavioral Health Assessor report. Personnel #1 stated I am not finding one. Personnel #1 looked for documentation again without finding any. Personnel #1 was asked if they stabilized Patient #1's his eating issue prior to discharge. Personnel #1 stated no. Personnel #1 asked if there was physician documentation of communication with mother/guardian. Personnel #1 stated no, no documentation of trying to talk to the mother after the ED (emergency department).

During a telephone interview on 8/10/2023 at 5:00 PM with physicians, Personnel #3 and #4 were asked when a patient does not eat - what measures should be taken to ensure life. Personnel #3 stated it depends on the situation. This patient ate at home. This patient was refusing food from us. He did not recognize us. He would take sips and bites only, then stop. He was like a child. The best place for him was home with his family. We can't force them to eat. We tried our best to feed the patient. The family was inconsistent. Nurses tried their best. Personnel #4 stated he was a difficult case because of all the social factors. APS (adult Protective Services) and the state were involved. They worked on placement and could not find placement for him. We can't tie him down to tube him when it isn't clinically indicated. He was stable, no signs of distress or dehydration, labs were good. Personnel #3 was asked if he spoke to mom. Personnel #3 stated I did the first day. Mom said she had to take care of the other kids. After day 1, Social Worker and Nursing kept in touch. At discharge, I spoke to mom. She was upset that patient would not have placement but discharged. I told her we needed the families help and no help came. He rejected our help because he doesn't recognize us. It is possible he was drinking when no one was with him. He used a sippy cup. No clinical signs of dehydration. We felt he would go back to eating when he was no longer in the hospital.

During record review and interview on 8/14/2023 at 1:52 PM, Personnel #2 was directed to the Order for Case management that said enteral feeding and the Home Health OT/PT/RN eval (Occupational/Physical Therapy and Registered Nurse). Personnel #2 was asked where these were addressed. Personnel #2 reviewed the record and stated I don't see it. Personnel #2 was asked if the hospital had a surgeon to place a G-tube. Personnel #2 stated yes.

https://www.chop.edu/treatments/gastrostomy-tubes
A gastrostomy tube, often called a G tube, is a surgically placed device used to give direct access to your child's stomach for supplemental feeding, hydration, or medicine. G tubes are used for a variety of medical conditions, but the most common use is for feedings to enhance your child's nutrition. When a child is unable to eat enough food by mouth, a G tube helps deliver enough calories and nutrients to support their growth.

The hospital's "Physician Orders" policy reflected, "To provide safe and timely administration of all physician orders..."

The SUBSEQUENT hospital's record reflected the patient was admitted on 5/17/2023 (same day) with dehydration and weighed 56.2 kilograms (Loss of 7 kilograms). An NG (naso-gastric) tube feedings were tolerated. A G-Tube was place on 5/23/2023 due to the patient's aversion to eat. Re-feeds started and he tolerated feedings prior to discharging on 5/24/2023 to a skilled nursing facility...brought in from an outside facility...they (outside hospital) discharged today despite not having clinical improvement. Family is very concerned that he is still not taking anything to eat or drink.

Based on record review and interview, the hospital failed to ensure the registered nurse supervised and evaluated the nursing care for each patient in accordance with the patient's needs,

citing for 1 of 20 patients (Patient #1) nursing did not follow the physician orders and meet the patient's needs while hospitalized from 5/13/2023 through 5/17/2023 and post-acute.

~ Failed to meet nutritional requirements.

~ Failed to monitor weight loss during the period of no intake.

~ Failed to have a physician order for IV (intravenous) fluid on 5/17/2023.

~ Failed to remove the intravenous catheter site prior to discharge.

~ Failed to act on the mother's complaint of negligence.

Patient #1's documented weights showed a loss of 7 kilograms/15.4 pounds since the 5/13/2023 admission.

Cross Reference Tag A0395

Based on record review and interview, the registered nurse failed to supervise and evaluate the nursing care for each patient in accordance with the patient's needs,

citing for 1 of 20 patients (Patient #1) nursing did not follow the physician orders and meet the patient's needs while hospitalized from 5/13/2023 through 5/17/2023 and post-acute.

~ Failed to meet nutritional requirements.

~ Failed to monitor weight loss during the period of no intake.

~ Failed to have a physician order for IV (intravenous) fluid on 5/17/2023.

~ Failed to remove the intravenous catheter site prior to discharge.

~ Failed to act on the mother's complaint of negligence.

Patient #1's documented weights showed a loss of 7 kilograms/15.4 pounds since the 5/13/2023 admission.

Findings

~ Failed to meet nutritional requirements

Patient #1 record reflected a 20-year-old incapacitated adult/child who is non-verbal, legally blind, autistic, intellectual disabilities who required total care including using a sippy cup, needing to be hand feed pureed food, given liquid medications, and changing diapers. The mother said the child had not eaten for five (5) days since the primary care giver (grandfather) was hospitalized on Monday (5/08/2023). The patient's primary caretaker was currently in the hospital. Patient has been refusing to interact and allow for care. Patient here is malodorous and does appear disheveled. The 5/13/2023 weight was 63.2 kilograms (139.04 pounds) on admission. The admit diagnosis was Failure to Thrive. Other diagnosis included dehydration; disorders of nutrition, metabolism, fluid; and hydrocephalus status post VP (ventriculoperitoneal) shunt. The patient was discharged 5/17/2023 without stabilization of the nutritional and psychological issues.

There was no nutritional intake, or hospital intervention implemented to ensure the child's nutritional requirements were met while the patient was hospitalized from 5/13/2023 through 5/17/2023 or post-acute.

Patient #1's 5/13/2023 Physician order reflected 10:50 AM Case Management...Enteral Feeding...

Patient #1's 5/15/2023 Nutrition Assessment reflected...refusing foods...nurse trying to feed...PO (by mouth) Intake zero percent for today's meals...weight kg (kilograms): 63.2...Nutrition Calculations - Calories a day: 1903...Nutrition problem 1: Inadequate oral intake...Chronic disease...Collaboration with other: Enteral Nutrition...currently on pureed diet/ no straw. patient is refusing to eat food. Recommend alternate source for nutrition....obtain 1 to 2 x (times) weekly weights for monitoring...

~ Failed to monitor weight loss during the period of no nutritional intake

Patient #1's 5/15/2023 Nutrition Assessment reflected...refusing foods...nurse trying to feed...PO (by mouth) Intake zero percent for today's meals...weight kg (kilograms): 63.2...Nutrition problem 1: Inadequate oral intake...obtain 1 to 2 x (times) weekly weights for monitoring...

There was no further weight documented while hospitalized from 5/13/2023 through 5/17/2023.

~ Failed to have a physician order for IV (intravenous) fluid on 5/17/2023.

The I&Os (Intake and Output) documentation reflected 5/17/2023 (day of discharge) 900 IV intake.

There was no order for IV fluids for 5/16/2023 or 5/17/2023.

The 5/17/2023 Nurse Note: 14:46 (2:46 PM) refusing anything by mouth...IV needs to be dc'd (discontinued)...

~ Failed to remove the intravenous catheter site prior to discharge

Nurse Notes: 5/17/2023 19:49 (7:49 PM) attempt to remove IV with patient mom assistance was unsuccessful. Patients' mom requested no restrain intervention to remove line. Patient was dc'd (discharged) with IV/non flushable, mom verbalized awareness.

~ Failed to act on the mother's complaint of negligence

The hospital's 5/17/2023 incident report documented multi-level care staff, supervisors, and management were aware of the mother's discharge complaints of the hospital's negligence to feed the child and her intent to take the child to a childrens hospital for care once they discharged him.

During record review and interview on 8/10/2023 at 10:23 AM, Personnel #1 navigated the records and confirmed the above findings. Personnel #1 was asked for the Behavioral Health Assessor report. Personnel #1 stated I am not finding one. Personnel #1 was asked if they stabilized Patient #1's his eating issue prior to discharge. Personnel #1 stated no.

Personnel #1 was asked if consumption of meals/calories/fluids was documented. Personnel #1 stated the only documentation is in routine daily care: appetite poor on the 13th at 15:50 (3:50 PM); 17th at 07:30 (7:30 AM) appetite poor; no other documentation found. The only oral intake was documented was 20 ml (milliliters) on the 18th the day after discharge. There is no IV order for the documented IV fluid intake of 900 ml on the 17th. There is no order for IV fluids after the 14th.

During record review and interview on 8/14/2023 at 1:52 PM, Personnel #2 was directed to the 5/13/2023 orders for enteral feeding and Home Health OT/PT/RN eval (Occupational/Physical Therapy and Registered Nurse). Personnel #2 was asked where this was addressed. Personnel #2 reviewed the record and stated I don't see it.

During record review and interview on 8/14/2023 at 4:32 PM, Personnel #2 was asked if the facility had a surgeon who could place a G-tube (Gastrostomy tube). Personnel #2 stated yes.

The hospital's July 2022 "Physician Orders" policy reflected, "To provide safe and timely administration of all physician orders..."

The SUBSEQUENT hospital's record reflected the patient was admitted on 5/17/2023 (same day) with dehydration and weighed 56.2 kilograms (Loss of 7 kilograms). An NG (naso-gastric) tube feedings were tolerated. A G-Tube was place on 5/23/2023 due to the patient's aversion to eat. Re-feeds started and he tolerated feedings prior to discharging on 5/24/2023 to a skilled nursing facility...brought in from an outside facility...they (outside hospital) discharged today despite not having clinical improvement. Family is very concerned that he is still not taking anything to eat or drink.

Based on record review and interview, the hospital failed to ensure an appropriate discharge plan to meet the medically-related needs of its patients that facilitated the provision of follow-up care and the results of the evaluation must be discussed with the patient (or the patient ' s representative);

citing 1 of 20 patients (Patient #1) discharge plan did not meet the needs of the patient and did not involve Patient #1's guardian.

Cross Reference A0808

Based on record review and interview, the hospital failed to ensure an appropriate discharge plan to meet the medically-related needs of its patients that facilitated the provision of follow-up care and the results of the evaluation must be discussed with the patient (or the patient ' s representative);

citing 1 of 20 patients (Patient #1) discharge plan did not meet the needs of the patient and did not involve Patient #1's guardian.

Patient #1's documented weights showed a loss of 7 kilograms/15.4 pounds since the 5/13/2023 admission.

Findings

Patient #1 record reflected a 20-year-old incapacitated adult/child who is non-verbal, legally blind, autistic, intellectual disabilities who required total care including using a sippy cup, needing to be hand feed pureed food, given liquid medications, and changing diapers. The mother said the child had not eaten for five (5) days since the primary care giver (grandfather) was hospitalized on Monday (5/08/2023). The patient's primary caretaker was currently in the hospital. Patient has been refusing to interact and allow for care. Patient here is malodorous and does appear disheveled. The 5/13/2023 weight was 63.2 kilograms (139.04 pounds) on admission. The admit diagnosis was Failure to Thrive. Other diagnosis included dehydration; disorders of nutrition, metabolism, fluid; and hydrocephalus status post VP (ventriculoperitoneal) shunt. The patient was discharged 5/17/2023 without stabilization of the nutritional and psychological issues.

Patient #1's record documented the 5/13/2023 physician orders:
07:33 AM Place call to BH (Behavioral health) assessor Psych / Abuse workup;

10:50 AM Case management...enteral feeding; AND

1:09 PM Case management...Home Health OT/PT/RN eval (Occupational/Physical Therapy and Registered Nurse).

There was no indication the orders were implemented/acted on.

There was no nutritional intake, or facility intervention implemented to ensure the child's nutritional requirements were met while the patient was hospitalized from 5/13/2023 through 5/17/2023 or post-acute.

The hospital's 5/17/2023 incident report documented multi-level care staff, supervisors, and management were aware of the mother's discharge complaints of the hospital's negligence to feed the child and her intent to take the child to a childrens hospital for care once they discharged him.

During record review and interview on 8/10/2023 at 10:23 AM, Personnel #1 was asked for the Behavioral Health Assessor report. Personnel #1 stated I am not finding one. Personnel #1 was asked for the order. Personnel #1 found the 5/13/2023 07:33 order. Personnel #1 looked for documentation again without finding any. Personnel #1 was asked if they stabilized Patient #1's his eating issue prior to discharge. Personnel #1 stated no. Personnel #1 asked if there was physician documentation of communication with mother/guardian. Personnel #1 stated no, no documentation of trying to talk to the mother after the ED (emergency department).

During an interview on 8/10/2023 at 4:00 PM with the social worker, Personnel #5 was asked to explain what occurred with the patient. Personnel #5 stated patient came in because of grandfather's medical complications. He lived with grandfather, and they admitted (Patient #1) because they were told he had no caregiver. Once I found out there was a state worker, APS (Adult Protective Services), and Lifepath. I coordinated with them. They (APS) spoke with mom. APS told me the mom was not able to care for him. Personnel #5 was asked I am hearing that you coordinated with everyone else, but did not talk to mom. Did you speak to mom. Personnel #5 stated only once to tell her he would discharge. Personnel #5 was asked as the patient advocate what should be done if a patient won't eat. Personnel #5 stated ensure he is getting nutrients to be healthy. Personnel #5 was asked why he was discharge if we did not take care of the eating issue. Personnel #5 stated he was discharged because the doctor ordered his discharge.

During record review and interview on 8/14/2023 at 1:52 PM, Personnel #2 was directed to the 5/13/23 Orders for enteral feeding and Home Health OT/PT/RN eval (Occupational/Physical Therapy and Registered Nurse). Personnel #2 was asked where this was addressed. Personnel #2 reviewed the record and stated I don't see it. Personnel #2 was asked if the hospital had a surgeon to place a G-tube. Personnel #2 stated yes.

The hospital's July 2022 "Physician Orders" policy reflected, "To provide safe and timely administration of all physician orders..."

The SUBSEQUENT hospital's record reflected the patient was admitted on 5/17/2023 (same day) with dehydration and weighed 56.2 kilograms (Loss of 7 kilograms). An NG (naso-gastric) tube feedings were tolerated. A G-Tube was place on 5/23/2023 due to the patient's aversion to eat. Re-feeds started and he tolerated feedings prior to discharging on 5/24/2023 to a skilled nursing facility...brought in from an outside facility...they (outside hospital) discharged today despite not having clinical improvement. Family is very concerned that he is still not taking anything to eat or drink.